Developing Best Practices for Increasing Breastfeeding in At-Risk Populations:

1. Developing Best Practices for Increasing Breastfeeding in At-Risk Populations: building partnerships for practice, advocacy andresearch Angela M Johnson, PhD, UMHS, Program for Multicultural Health & Jennifer Day, Chairperson, Oakland County Breastfeeding Coalition October 23, 2014 Michigan Premier Public Health Conference Shanty Creek Resort Bellaire, Michigan

2. Session Goals • Overview: Strategic Planning for Breastfeeding Coalitions • Why Advocacy Matters: MIBFN as an Example • Breastfeeding in Michigan • Using Partnerships: to Advance Practice, Capacity, and Research • Best Practices: for Advancing Breastfeeding in the Community • Q & A • Presenter info and contact

3. Strategic Planning for the Michigan Breastfeeding Network •Explain the history of our strategic planning process •Provide a roadmap of our plan •Discuss our challenges and successes in implementation

4. WHAT IS STRATEGIC PLANNING? an organization's process of defining its strategy, or direction, and making decisions on allocating its resources to pursue this strategy Source: Mintzberg, et. al. The Strategy Process,

5. MIBFN: Three Year Plan •Goal 1: Strengthen Ourselves -MIBFN will become an independent 501(c)3 organization with paid staff members and a Board of Directors that implements best practices in financial management, fundraising, and communications. •Goal 2: Build the Network- MIBFN will grow and diversify its membership to better represent the spectrum of statewide and local community breastfeeding stakeholders. •Goal 3: Support Local Coalitions - MIBFN will guide emerging local/regional coalitions and strengthen existing local/regional coalitions by offering technical assistance and educational resources. •Goal 4: Optimize Society- MIBFN will lead and participate in collaborative advocacy efforts to promote, protect, and support breastfeeding policies.

6. MIBFN Mission and Vision •The mission of the Michigan Breastfeeding Network (MIBFN) is to optimize state and community support of breastfeeding by leading collaborative actions for advocacy, education, and coalition building. •MIBFN envisions that state and local communities recognize breastfeeding and human milk as the norm for infant and young child feeding, and all families will live, work, and receive support in a breastfeeding-friendly culture.

7. Our Work •Advocacy MIBFN works to improve the legislative, workplace and cultural breastfeeding climate in Michigan through advocacy activities and events. •Coalition Building MIBFN organizes, supports and activates local and community breastfeeding coalitions in their efforts to encourage, educate and support breastfeeding mothers in Michigan. •Education MIBFN provides resources for health care providers, employers and breastfeeding mothers to aid in fostering breastfeeding success in Michigan.

8. Methodology •Business Case for Breastfeeding Toolkit •Advocacy Committee •Advocacy Day at the State Capitol •Passing Breastfeeding Anti-Discrimination Act •Breast Pumps for Medicaid Moms in NICU •Exploring fiscal sponsorship for regional coalitions

9. MAJOR WIN Passed the Breastfeeding Antidiscrimination Act June 24, 2014

10. “AN ACT TO PROHIBIT DISCRIMINATORY PRACTICES, POLICIES, AND CUSTOMS IN THE EXERCISE OF THE RIGHT TO BREASTFEED; TO PROVIDE FOR ENFORCEMENT OF THE RIGHT TO BREASTFEED; AND TO PROVIDE REMEDIES.” Michigan Breastfeeding Anti-Discrimation Act

11. KEY COMPONENTS OF THE LAW • A mom can breastfeed in a place of public accommodation. For example, a restaurant, school, courthouse, library, bus, train, and/or retail store • A breastfeeding mom cannot be denied service because she is breastfeeding. Also, the business cannot ask moms not to breastfeed or ask a mom to leave the premises because she is breastfeeding. • If someone violates this law, the aggrieved mom can bring a claim in civil court for damages of $200.00

12. Partnerships Through Research: Moving Toward Community Partnered Participatory Research (CPPR)

13. Translational 2-Pronged Research Process: • Systematic Literature Review social ecological perspective as guiding framework to systematically review BF interventions (Johnson, et al, In press, Journal Breastfeeding Medicine) • Qualitative Investigation: Focus Group Study conducted in Metro-Detroit to discover effective BF interventions for AA women (Johnson, et al Feb 2015, Journal Human Lactation) This U-M study was supported by grant number 2UL1TR000433 from the National Center for Advancing Translational Sciences, National Institutes of Health.

14. Systematic Literature Review of BFInterventions (Methods) • searched CINAHL, PubMed, Web of Science,Google scholar, and other databases • key words:“breastfeeding”, “breastfeeding interventions”, “breastfeeding strategies”, “breastfeeding support”, “African American mothers”, “Black mothers”, etc. as key concepts in title, abstract, key words • study sample significant (30% or more) AA • limited to research studies published during the 1995-2013 • primary focus was on BF interventions or strategies

15. Literature Systematic Review Results • yielded 506 studies • 32 studies met the inclusion criteria; full-text considered • Some eliminated b/c discussed BF barriers but no interventions or strategies • 24 papers met inclusion criteria and underwent content analysis

16. Systematic Review Findings Successful BF Interventions: • Have psychological & educational component • Target moms pregnancy thru postpartum • promote mother’s BF “readiness” (e.g. Pugh, 2010) • Incorporate team approach: LC, BF peers, family, etc. • Provide in-person (& phone-based) support Missing: none address major risk factors for BF: • culture/neglect (most studies have low-income samples) • stress/mental health (populations with these indicators were often eliminated from study samples) • Lack of workplace support

18. Why partnerships in research are important for breastfeeding BF has tremendous health benefits for mother & baby • Persistent maternal & infant health disparities among Afri Amer mothers lower overall BF rates • Few interventions address BF disparities in Afri Amer populations • historical lack of trust & negative experiences w/healthcare professionals • BF systemic problem require systemic solution • Current models based on researchdemonstrate an opportunity

19. Percentage infants BF by birth cohorts & race/ethnicity 1999-2006 (McDowell, 2008: NHS data)

20. Risk Factors that Undermine BF in AA women are: • Historical/cultural • Greater exposure to risk factors (depression, poverty, unsupportive work environment, access issues to BF resources…) • Individual (low self-efficacy…) • Shorter maternity leaves on average • Lack workplace support (focus group study)

21. What is CPPR? Community Partnered Participatory Research a form of CBPR(Community based Participatory Research) developed by Healthy African American Families and Charles R. Drew Medical University with support from the CDC, emphasizes authenticcommunity-academic partnerships& building capacity for partnered planning and implementation of research-informed programs

22. CPPR Process • Identify a health issue that fits community priorities and academic capacity to respond; • Develop a coalition of community, policy, and academic stakeholders that inform, support, share, and use outcomes; • Engage the community through meetings that provide information, determine readiness to proceed, and obtain input; • Initiate work groups that develop, implement, and evaluate action plans... (Loretta Jones, January 2007 Academic and Clinician Engagement in CPPR)

23. Focus Group Study

24. Some Focus Group Questions • What influences decisions to BF? To bottle feed? • If we were to design a program that effectively helps mothers start & continue BF what would it look like? • How do we support physical and mental health problems with mothers, baby? • Thinking about social support, what type (emotional e.g. listening, advice, etc.) and from who? e.g. family, friends, baby’s dad?, a health care provider e.g. lactation consultant, obstetrician, mid-wife, pediatrician, primary care doctor, etc.?, and when? e.g pregnancy e.g. post partum?)

25. Focus Group Format • Group is seated in circle • Digitally Audio-recorded • Lead facilitator & co-facilitator • Handwritten notes • Transcribed verbatim • Coded for analysis • Approx 60 min in length

26. Community Focus Group Participants

27. Mom Demographic Profile n = 29 • Detroit & Ypsilanti equally represented • 79% $0-14,999; 10% $15-30k; 10% $31-75K • Average age = 25 • 52% have some college or more • 37% high school only • 10% < high school • 22 single/never married; 3 married; 3 divorced • 20 current parents; 9 pregnant • 15 BF/planning to; 10 formula/planning to; 4 both/planning both

28. BF Professionals Demographicsn = 9 • Lactation consultants • BF Peer counselors • Community Health Advocates • Aged 30-60 • Evenly distributed across race

29. Study Participant Feedback

30. Moms need personal support to prepare & to BF Moms believe BF is healthy but.. BF Requires Confidence & Trusted Social Support • But often did not trust info/advice from healthcare; felt H.C misinformed, misdirected (e.g. med safety • tended to BF when a family member or friend BF • tended to BF when they had planned & received personal & clinical, and support pregnancy thru postpartum • Public BF backlash is common place • Moms are coping w/stress due to homelessness, poverty, illness, short maternity leaves, domestic violence, unsupportive work environments, made BF less priority • Successful BF moms were often part of a peer BF grp were they received ongoing emotional support & educ; or they created their own community

31. Moms need continuum BF Education Mothers need info and skill-building support BF support should be practical and accessible • Include facts & myths • Topics such as: Medication safety, latch-on technique, managing return to work, public BF • How-to’s on develop virtual BF communities, groups • Friendly, inclusive • Comfortable, accessible, non-medical setting • Led by AA woman • Individual & group-based • Peer-oriented • Host other groups for father, grandparents, friends

32. Partnerships reflect need for Social Ecological Perspective • Practice, advocacy, and research designed to enhance BF are not possible without partnerships • Organizations should reflect multi-sectorial approach: • Black Mothers Breastfeeding Assoc. (Grassroots) • Corner Health (Healthcare-Community) • Destiny & Purpose Community Outreach (Grassroots) • EMU, Self-Sufficiency Program (Community • U-M Program for Multicultural Health (Ypsi) • Washtenaw Co WIC (Ypsi) • Women Inspired Neighborhood Network (Detroit)

34. Source: http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf

35. Source: http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf

36. Source: http://www.cdc.gov/prams/data-breastfeeding.htm

37. Source: http://www.cdc.gov/prams/data-breastfeeding.htm

38. Work of advocacy, research & practice show partnerships reflect critical approach • BF requirescomprehensive education & role modeled BF support from trusted sources at multiple levels** • BF Interventions must help mothers manage BF with multiple barriers: life demands, physical & mental challenges, lack workplace support, lack family, personal support, and inadequate healthcare support • thus...BF interventions require that we engage multiple social institutions: hospitals, workplace, schools, churches, etc. in: “BF initiatives that function comprehensively, operate seamlessly, from the societal level of national-, state-, & local-level policy & be incorporated throughout major social institutions” (Johnson et al In press 2015 Journal Breastfeeding Medicine)

39. Questions

40. Presenters & Contact Info. Angela Johnson, Program Manager for the Program for Multicultural Health at the University of Michigan Health System, Ann Arbor campus & most recently a Postdoctoral Research Fellow with the Michigan Institute for Clinical Health Research (MICHR) at the University of Michigan. Angela is also a member of the Board of Directors for Black Mothers Breastfeeding (BMBFA); BMBFA provides advocacy, guidance, & support to address breastfeeding disparities in Michigan. She has published a number of articles on the sociocultural context of breastfeeding & provides ongoing support to several community initiatives that support African American mothers and their children. Angela is the proud mother of three breastfed children, Khai, Olivia, and Kaleb and lives quietly with them and her husband, Oliver. Website: www.med.umich.edu/multicultural/ Email: angejohn@umich.edu Jennifer Day is Chairperson of the Oakland County Breastfeeding Coalition, WIC Breastfeeding Peer Counselor with Oakland Livingston Human Service Agency (OLHSA), and social media consultant with Best For Babes Foundation. The married mother of two exclusively breastfed children, endeavours to bring best practices to mothers and educate the public, in an effort to create breastfeeding positive spaces in underserved communities in the area. She is also a consultant with Black Mother’s Breastfeeding Association (BMBFA), educating Health Professionals nationwide as one of several workshop facilitators, discussing “Cultural Competence in Breastfeeding Support for African Americans”. Website: oaklandcountybfingcoalition.weebly.com Email: jenniferd1@olhsa.org